(September 16, 2008 - Insidermedicine) Welcome to Insidermedicine's If I Had, where we get a chance to ask an expert what they would do if they had a medical condition.
On a recent trip to Palo Alto, we caught up with Dr. Steven Chang, MD, who is the Director of CyberKnife Radiosurgery at Stanford Hospital & Clinics, and is also an Associate Professor of Neurosurgery at the Stanford University School of Medicine. Dr. Chang’s extensive clinical research studies include the treatment of cerebrovascular disorders, as well as the use of radiosurgery to treat tumors and vascular malformations of the brain and spine.
If I had the worst headache of my like…
There are several things I would look for. First I would want to get to medical care as soon as possible. This is not a situation where I would want to stay at home to see if headache got better. I’d want immediate medical attention. The speed at which you get medical attention somewhat determines your outcome. The second thing that I would want is to b treated at a medical center that has significant experience in managing aneurysms. Aneurysms are not very easy medical problems to treat. SO I would want to be treated at a medical center that has a great deal of experience with treating aneurysms. Both with surgical techniques in the operating room, and with endovascular techniques in the catheter angiography lab. I think having both of the modalities available will allow me to receive optimal treatment for my ruptured aneurysm.
What is the first thing I should do if I have the worst headache of my life?
If you are dealing with the worst headache of your life, these are typically headaches that are not run-of-the-mill routine headaches. These are headaches will be able to tell you specifically that something is wrong. With these type of headaches its very important that you get to the hospital as quickly as possible. That typically requires calling 911. Many times patients with the worst headache of their life often have significant neurologic issues. For example they may have difficulty with movement. They may have difficulty with speaking. Often times its not the patient but a family member that ends up calling 911 and getting them to the emergency room as quickly as possible.
What questions should the doctor be asking?
The primary difference between intracranial hemorrhage headaches and run-of-the-mill headaches are several fold. First is the abruptness of onset. A typical run-of-the-mill tension headache come on gradually, over minutes to half an hour for example. Whereas a ruptured aneurysm type headache will be a split second onset of a headache. Its often called a thunderclap headache because you are fine one minute, and the next minute you have this horrendous headache that patients describe as greater than ten out of ten on a pain scale. The second variable that the physicians in the emergency room will look at is the other symptoms associated with the headache. A headache from a ruptured aneurysm will often be associated with severe neck pain. Oftentimes nausea and vomiting, and what we call photophobia, which is bright light bothering the patients eyes. They often like to keep their eyes closed and lie in a dark room.
What are some important diagnostic tesst to diagnose aneurysms?
The first test that is typically done in the emergency room with a patient comes in with the worst headache of their life is a CT scan, or CAT scan of the patients brain. This is a quick study that can be done over two to three minutes, and will allow us to detect blood in the brain. It’s the primary test that is utilized. Certain types of bleeds from aneurysms can be so subtle, meaning the amount of blood is very small, that one can miss it on a CT scan. In that case a lumbar puncture is performed. Its often called a spinal tap. Where a needle is placed into the spinal fluid in the lower back and that fluid is sampled. The fluid should be clear. If you have had a ruptured aneurysm for example the fluid will be dark red and that is a second test. Most of the time the CT scan can make the call in terms of diagnosing blood in the brain.
Are there any other types of bleeds that can occur in the brain?
We have been focusing on aneurysm ruptures as a source of the bleed and I should step back and say that aneurysm ruptures are one type of bleed in the brain. So if we are focusing first on aneurysm bleeds the next step typically after the CT scan is either a CT angiogram or a cerebral angiogram. These are studies that will identify the location of the aneurysm, the size of the aneurysm, and the number of aneurysms. Some patients have more than one aneurysm. Once you know those variables you can determine the actual treatment for these aneurysms. Treatment for aneurysms is primarily one of two types. The first type is surgery under a microscope to place a tiny metal clip across the aneurysm, it looks like a little clothespin, you are tying the aneurysm off, or clipping it off. The second type of treatment is endovascular coiling, The aneurysm is filled from the inside with platinum coils that seal off the aneurysm from the inside. Those are the two treatment options. Not all aneurysm can be treated by both options. The best settings to treat these ruptured aneurysms are hospitals that have both types of procedures available so that one can choose the optimal procedure for the patient. The other types of bleeds that can occur in the brain can occur from an AVM. AVM is an abbreviation for Arteriovenous Malformation. That’s an abnormal cluster of blood vessels in fact it looks somewhat like a raspberry, in that the blood vessels are reddish and purple. They can rupture and cause bleeding. These AVMs are similar to aneurysms, once they bleed we oftentimes try to treat them. The treatment can be either surgery or it can b focused radiation with a machince called the Cyberknife.
Am I at risk for aneurysms elsewhere?
We do know that patients with a single aneurysm have a risk of a second aneurysm in their brain. It’s thought that this may be ten to twenty percent of patients with a single aneurysm, may have more than one aneurysm. The reason for that is thought to be some structural flaws in the walls of the blood vessels themselves. A patient may have a genetic syndrome or type of disorder. For example Marfan Syndrome is a connective tissue disorder in which the blood vessels are not of normal strength. Weaknesses can develop in those blood vessels and you can develop multiple aneurysms.